Acute Pulmonary Edema and NSTEMI

Audience Emergency medicine residents and medical students on emergency medicine rotation. Introduction Acute pulmonary edema is a common and potentially fatal presentation in the emergency department. More than 1 million patients are admitted annually with a diagnosis of pulmonary edema secondary to cardiac causes.1 Pulmonary edema is broadly split into two main categories: cardiogenic and noncardiogenic. Cardiogenic pulmonary edema is characterized by acute dyspnea caused by the accumulation of fluid within the lung’s interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures.2 Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure.2 These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema. Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%.3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography.4 Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction. Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment. Educational Objectives At the end of this practice oral boards case, the learner will: 1) recognize unstable vital signs (VS) and intervene to stabilize ventilation and oxygenation, 2) demonstrate the ability to obtain a complete medical history including the important characteristics of chest pain, 3) demonstrate an appropriate exam on a patient, 4) order the appropriate evaluation studies for a patient with complaints of dyspnea, 5) interpret the results of diagnostic evaluation and diagnose Non- ST elevation myocardial infarction (NSTEMI) and pulmonary edema, 6) order appropriate management of pulmonary edema and NSTEMI, and 6) demonstrate effective communication with patient and family members. Educational Methods Practice oral boards Research Methods Immediate Feedback was solicited from the learners and observers participating in the case both by verbal discussion and completion of a rating for the case following the debriefing. The efficacy of the educational content was assessed by comparing scoring measures across residents based on the training year. Scoring measures of the American College of Graduate Medical Education (ACGME) core competencies were performed using a scale from 1 – 8, 1–4 being unacceptable performance and 5 – 8 being acceptable. Efficacy was assumed based on full completion of the case by the residents who acted as practice oral board candidates, and a debriefing session followed to discuss the key components of the case. Results This case was presented to twelve Emergency Medicine Residents, seven PGY 1 and five PGY 2 at a relatively new residency program. The overall average score for the residents was 5.62. The PGY 1 Residents’ average on the case was 5.56, and the average for the PGY 2 Residents was slightly better at 5.70. The slight improvement noted by the PGY 2 Residents is likely attributable to more clinical experience; however, both classes did not have any prior exposure to the oral board format until this simulated experience. Six residents completed all critical actions in the case. Of those who missed a critical action, failing to diagnose NSTEMI and consulting cardiology were the most common. All learners found educational value in the case with an overall rating of 4.83 (1–5 Likert scale, 5 being excellent). Discussion Acute pulmonary edema and NSTEMI are common diagnoses that will be frequently encountered for most emergency physicians. This case highlights the need for early identification and aggressive management of the patient presenting with respiratory distress. The differential for respiratory distress is large, but most learners were able to quickly identify pulmonary edema based on the exam findings of jugular vein distention (JVD), rales, and lower extremity edema. Most learners quickly escalated to a non-rebreather mask and ultimately to BPAP (bilevel positive airway pressure) without requesting to intubate the patient. There was notable variation in the approach to administering nitrates, but most ordered an intravenous (IV) nitroglycerin (NTG) drip and requested pharmacy assistance in dosing. Diuretics were ordered by all the learners, but some were hesitant to start early because they felt the effect would be delayed. Some of the residents did not identify ischemic changes on the EKG at first glance but did request to review a second time when the troponin result was positive. All residents gave aspirin after noting the positive troponin, but not all were able to make a clear diagnosis of NSTEMI or consult cardiology. Although the case was relatively straightforward, residents enjoyed early diagnosis and aggressive management of the patient with impending respiratory failure. Many residents are asking for an ultrasound early in the workup of this patient presenting in respiratory distress. Although not a critical action in this case, it highlights the emphasis placed on ultrasonography in the current emergency medicine curriculum. Topics Pulmonary Edema, Cardiovascular emergencies, NSTEMI.

ed cardiac filling pressures. 2Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure. 2These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema.Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%. 3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography. 4Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction.Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment.

Educational Objectives: At the end of this practice oral boards case, the learner will: 1) recognize unstable vital signs (VS) and intervene to stabilize ventilation and oxygenation, 2) demonstrate the ability to obtain a complete medical history including the important characteristics of chest pain, 3) demonstrate an appropriate exam on a patient, 4) order the appropriate evaluation studies for a patient with complaints of dyspnea, 5) interpret the results of diagnostic evaluation and diagnose Non-ST elevation myocardial infarction (NSTEMI) and pulmonary edema, 6) order appropriate management of pulmonary edema and NSTEMI, and 6) demonstrate effective communication with patient and family members.


Educational Methods: Practice oral boards


Linked objectives and methods:

The presented case requires the residents to care for the patient presenting in acute respiratory distr

s.The resid
nts must be able to quickly manage impending respiratory failure and treat it aggressively to avoid the

atient deteriorating.They must
e able to perform a full history and physical exam to arrive at the diagnosis of pulmonary edema and NSTEMI amongst a very wide differential diagnosis for respiratory distress.The oral board format worked best for this case so learners could troubleshoot the escalation of oxygenation and ventilation techniques, manage multiple medications, and navigate multiple conversations between the patient, family, and cardiology and ICU consultants.


Recommended pre-reading for instructor:

• None, review references as needed


Results and tips for successful implementation:

This case is best implemented using the oral board simulation as structured by the American Board of Emergency Medicine (ABEM).

arners were shown an instructional video
from ABEM prior to starting the case

to familiarize them with the format and structur
of the real oral boards.This case was presented to seven PGY 1 and five PGY 2 Emergency Medicine Residents.Following the case, direct feedback was given to the learner with specific focus and education on the critical actions of the case.

Learners were graded on a scale of 1-8 based on the ACGME core competencies as well as their ability to complete the six critical actions in this case.Results were recorded on a grading sheet by each examiner and submitted with data input into a Microsoft Excel spreadsheet.The learners had an overall score of 5.62 (1-4 unacceptable performance, 5-8 acceptable) with six of the twelve learners meeting all critical actions.The PGY 1 Residents average on the case was 5.56 and the average for the PGY 2 Residents was slightly better at 5.70.Following the case, learners were given a survey rating the educational value of the case using the Likert scale (1-5, 5 being excellent).The case was found to hold educational value to all the learners with a score of 4.83.There were no major modifications needed in this case, and the learners overall felt the case to be relatively straightforward.

There was some additional prompting needed to call cardiology to discuss the NSTEMI, and some learners required prompting to further discuss the history of chest pain once they became focused on treating the pulmonary edema.Most learners requested to start a nitroglycerin drip, but many were not sure of an appropriate starting dose and requested to have the pharmacy dose the medication.Overall, we feel this is a frequently encountered scenario in the emergency department and learners will benefit from keeping a broad differential with a focus on aggressive management of the patient in respiratory distress.


References


Oral Case Summary

Diagnosis: Pulmonary Edema and NSTEMI Case Summary: The patient is a 62-year-old female, Mrs. Poppyfield, who is brought from home by her daughter and husband.She is complaining of shortness of breath (SOB) since the morning and has

has had dyspnea on exertion (DOE) and
1-pillow orthopnea for at least one week, and she noted lower extremity edema beginning three days prior to arrival.She complains also of chest pain, located anteriorly, which began about the same time that shortness of breath began.Exam reveals a patient in severe respiratory distress with rales bilaterally which needs to be addressed emergently by placing the patient on CPAP (continuous positive airway pressure) or BPAP.After being placed on ventilation assistance, the history and physical should continue.The exam demonstrates tachycardia but normal heart tones, hypertension (HTN), and lower extremity edema.The patient is treated with intravenous nitroglycerin and furosemide.An EKG is performed which demonstrates ischemic changes, and the troponin returns elevated.The patient is diagnosed with NSTEMI and admitted to intensive care.Cardiologist is consulted and enoxaparin or heparin is administered.

Order of Case: Patient arrives by private car with daughter and husband.The learner performs the ABC's.The learner recognizes that the patient is in severe respiratory distress but has an adequate airway.The learner immediately orders oxygen [preferably 15 Liter (L) nonrebreath r but may ask for high flow oxygen (O2) or positive pressure ventilation)], cardiac monitor, saline lock or IV, and pulse oximeter (ox).The learner asks that blood be drawn and sent for laboratory testing.The learner performs a quick assessment of the lungs, cardiovascular and neurologic systems.The candidate should ask the examiner about a reassessment of the pulse oximeter and respiratory effort, but if the learner does not ask, the nurse should make a remark that, "the pulse ox is 90% on 15 L nonrebreather and it still looks like she is having a hard time breathing."Repeat vital signs: 186/104, 128, 26.The learner should then request CPAP or BPAP (pressure settings should be at least 8/5 and dial upwards with a maximum of 15/10) to ease the respiratory distress.Upon reassessment, the patient's respiratory rate decreases and the pulse ox improves to 94%.Vital signs after positive pressure ventilation administered: 190/110, 112, 18; pulse ox 95%.The learner then completes the history by gathering information from the patient, husband, and daughter.The patient tells the learner about accompanying chest pain.The learner needs to ask all pertinent questions about the history, events, and characteristics of the chest pain including quality, location, radiation, onset, duration, severity, aggravating or relieving factors, associated symptoms including cough, fever, SOB, nausea, vomiting, diaphoresis, lightheadedness, syncope, palpitations.Score up if the learner asks about risk factors for pulmonary embolism.

The learner should prioritize ordering a 12 Lead EKG and interpret it as Sinus Tachycardia with ST depression in the inferior lateral leads, recognizing that the patient's EKG demonstrates a high risk for unstable angina or non-ST elevation MI.The learner may ask for an old EKG but no old EKG is available.The learner should order aspirin, either 162 mg or 325 mg.If the learner does not give immediately, the aspirin must be given before the end of the case.The learner also prioritizes ordering a portable CXR.The learner may choose to use the ultrasound at any time during the assessment to determine if the patient is in pulmonary edema.There is an ultrasound that is provided that demonstrates B-lines.Do not score down if the learner does not use the ultrasound though.The physical examination should be performed around this time.The learner also orders complete blood count (CBC), chemistry, troponin (high-sensitivity troponin is used in this case), B-Type Natriuretic Peptide (BNP), venous blood gas (VBG) or arterial blood gas (ABG).Once either the CXR or US has been done, the diagnosis of pulmonary edema should be made and the learner should order a diuretic and nitroglycerin.The results return and the learner makes the diagnosis of pulmonary edema and NSTEMI, consults cardiology, and admits the patient to the ICU.The learner may also decide to give Enoxaparin (Lovenox), heparin, or may elect to discuss it with the cardiologist.

The learner explains everything to the patient, husband, and daughter.


Historical Inf rmation

Chief Complaint: Dyspnea History of present illness: 62-year-old female, Mrs. Poppyfield, who is brought from home by her daughter and husband.She is complaining of shortness of breath since the morning and has progressively become much worse.She has had dyspnea on exertion (DOE) and 1-pillow orthopnea for at least one week, and s e noted lower extremity edema beginning three days prior to arrival.She complains also of chest pain, located anteriorly, which began about the same time that shortness of breath began.She describes the pain as constant tightness without radiation, 6/10 in in ensity.She cannot identify any relieving or aggravating factors.She deni

nausea, vomiting, palp
tations, and lightheadedn ss.She does have a nonproductive cough.She denies fever but became diaphoretic when the shortness of breath became worse.She has never had one of these episodes before.Cueing Guideline (if applicable): If the learner does not order a change from 15 L nonrebreather to positive pressure ventilation, the nurse should give the information that the pulse oximeter remains low and that the patient keeps pulling off the mask.If giving more than two prompts for this, score down.


Past Medical History


Critical Action 2: Orders 12 Lead EKG early Patient care, systems-based practice

This critical action is met by the learner's ordering a 12 Lead EKG and then interpreting the results.

Cueing Guideline (if applicable): If the learner fails to order a 12 Lead EKG, the nurse should ask a general question after starting the IV and collecting the blood specimens, "Is there anything else you want done or ordered?"If the learner still does not order the EKG, the nurse should mention the rapid heart rate and ask if it is sinus tachycardia.


Critical Action 3: Orders aspiri , nitroglycerin, furosemide, enoxaparin or heparin. Patient care, medical knowledge

This critical action is met by the learner's ordering aspirin (162 -325 mg PO), nitroglycerin (can start with sublingual at 0.4 mg and then 0.5 -0.7 micrograms/kg/minute intravenously every few minutes, checking blood press

e and symptom relief), furosemide (40 -80 mg intravenously), enoxaparin (1 mg/kg
ubcutaneously) or IV heparin (bolus followed by continuous infusion; may request pharmacy to dose)

Cue ng Guideline (if applicable): If the learner does not order nitroglycerin, the nurse should ask if the learner is concerned about how high the blood pressure is.If the learner does not order furosemide, the nurse should ask if any other medications need to be given.If the learner does not order aspirin, the nurse should ask if there any medications indicated for the patient's complaints of chest pain.If the learner does not order enoxaparin or heparin, the cardiologist should ask if any anticoagulants have been given.


Critical Action 4: Explains results of evaluation to patient, husband and daughter. Interpersonal commun

al action is met by the learner's explaining the results of the eva
uation and the diagnosis to the patient and family and informing them of the cardiology consult and admission to the hospital.

Cueing Guideline (if applicable): If the learner does not take he time to inform the family of the evaluation and plan, the nurse should tell the learner that the husband is asking questions and would like to know what is wrong with his wife and will she be getting better.


Critical Action 5

Diagnoses Non-ST elevation MI Medical knowledge

This critical action is met by the learner explai
ing to the patient and family or the cardiologist that the troponin is elevated, and the EKG shows ischemic changes which diagnose a NSTEMI.

Cueing Guideline (if applic

le): If the learner doe
not use the term, NSTEMI in the conversation, the family or the cardiologist should ask if the learner thinks that the patient had a "heart attack" or "myocardial infarction."


Critical Action #6: Consults cardiologist Professionalism, interpersonal and communication skills

This critical action is met by the learner's asking to speak to the cardiologist and reviewing the patient's history and physical, treatment, present condition, results

of the evaluation and making the diagnosis of NSTEMI and the plan for admission.

Cueing Guideline (if applicable): If the learner does not consult a cardiologist, the intensivist should sk, "Do you think that the patient needs to go the cath lab emergently?"


Scoring Instructions 5

It was decided to reproduce the mock oral boards to be as indistinguishable from the actual ABEM oral boards as possible, so the 1-8 scoring system that ABEM uses on the oral boards was employed.The actual oral boards do score similarly to the core competencies, but do not produce a detailed score as a milestone assessment.We are providing both the rating system that we used and the milestones assessment which can both be filled out or elected to use only one scoring system at a time.The faculty were provided with the guidelines below as well as the scoring sheet and flow sheet to enhance the ability to collect information.

The scoring instructions for the 1-8 score are: Score 1 or 2: Very Unacceptable: learner was unable to propose diagnostic evaluation, management beyond the most basic because the medical condition, the abnormalities, etc. were unrecognized or the learner does not have the needed knowledge.The learner may recognize the medical condition or disorder but exhibits gross negligence or gross mismanagement.Score 3 or 4: Unacceptable: If a learner omits a critical action they should not be scored higher than a 4 in that category.Even if critical actions are not omitted, the medical management is inco plete, unorganized, or unsatisfactory.It is evident that the learner has only partial knowledge of the pathophysiology.Score 5 or 6: Acceptable: The learner demonstrates the ability to practice medicine safely.The patient in the case received an appropriate and safe medical evaluation and treatment.Only some minor omissions or errors were noted, and they did not affect the overall outcome of the case.Score 7 or 8: Very Acceptable: The